Complications and mortality associated with olecranon fractures in the elderly: a retrospective cohort comparison from a large level one trauma centre

Mortality and subsequent fractures of patients with olecranon fractures compared to other upper extremity osteoporotic fractures

Background

The incidence rate of olecranon fractures is highest in the elderly population. The aim of this study was to determine whether patients with olecranon fractures have similar demographic and risk characteristics compared to patients with osteoporotic upper extremity fractures.

Methods

A retrospective data analysis was performed with diagnoses for olecranon fracture, distal radius fracture and proximal humerus fracture between 2014 and 2016.

Results

A total of 157 olecranon, 1022 distal radius and 451 proximal humerus fractures were identified. The risk of mortality after olecranon and distal radius fractures was comparable but statistically significantly higher after proximal humerus fractures (HR 1.97, 95% CI 1.19-3.27). The risk of subsequent osteoporotic fractures after an olecranon fracture was 10% at 1 year and 14% at 5 years and the risks did not differ statistically after a proximal humerus fracture, 6% and 11% (HR 0.65, 95% CI 0.40-1.06). After a distal radius fracture, the risks were statistically significantly lower: 2% and 5% (HR 0.35, 95% CI 0.22-0.56).

Discussion

Patients with olecranon fractures have essentially similar demographic characteristics compared to patients with distal radius fractures, but the probability for a subsequent fracture is significantly higher and more comparable to patients with proximal humerus fractures.

Treatment of olecranon fractures in older individuals: a cross-sectional survey of surgeon treatment preferences

Background

With an aging population, the incidence of olecranon fractures in older patients is increasing. The standard of care has traditionally included operative management for displaced fractures. Recent literature has called this standard of care into question. Older patients may be at increased risk of operative complications and may have satisfactory functional outcomes with nonoperative management. Given recently evolving evidence, the current treatment preferences of orthopedic surgeons for older patients with displaced olecranon fractures are unknown.

Methods

We administered a cross-sectional survey of Canadian orthopedic surgeons via e-mail invitation and online survey form to determine treatment preferences for patients aged 65-75 and >75 years with simple displaced and comminuted displaced stable olecranon fractures. Respondents reviewed representative images and were asked to indicate their preferred treatment based on patient age. We also asked respondents to indicate their perceived importance of 11 patient factors on treatment decision-making.

Results

We received 200 responses (33.8% response rate). For patients aged 65-75 years with simple displaced fractures, surgeons preferred tension-band wiring (n = 110, 56%) to plating (n = 82, 42%, P = .005), while only 3% (n = 5) preferred nonoperative treatment. For patients aged >75 years with simple displaced fractures, surgeons preferred operative (n = 144, 73%) to nonoperative management (n = 51, 26%; P < .01) with either tension-band wiring (n = 77, 39%) or plating (n = 67, 34%). In these patients, early range of motion (n = 35, 18%) was preferred to immobilization (n = 16, 8%; P = .004). For comminuted fractures, plate fixation was preferred for patients aged 65-75 years (n = 189, 95%) and >75 years (n = 131, 68%). In patients aged >75 years, this was followed by early range of motion (n = 35, 18%) and immobilization (n = 24, 13%). Of the 11 factors surveyed, participation in high-intensity activities (mean rank = 9.4), independent living (mean rank = 8.8), and disrupted extensor mechanism (mean rank = 8.3) were ranked most highly for increasing likelihood of surgical treatment.

Conclusion

In patients aged 65 to 75 years, operative management is favored by most surgeons, with tension-band wiring preferred over plating for simple displaced fractures. In patients aged >75 years, operative management is again preferred by most respondents for simple and comminuted fractures. Despite operative preferences, there is a paucity of quality evidence to guide treatment decision-making, particularly in patients aged >75 years.

Olecranon fractures : current treatment concepts

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.Cite this article: Bone Joint J 2023;105-B(2):112-123.

Olecranon fractures: applied anatomy, clinical assessment and evidence-based management

Olecranon fractures are common injuries, making up 10% of all fractures of the upper limb. They usually result from a fall from standing height in older people, or from a direct blow in young people. The olecranon's superficial location, with poor soft tissue and muscle protection, make it liable to fracture following direct impact.

Factors such as the degree of initial force and the quality of the patient's bone result in a range of injury patterns, from simple undisplaced fractures to complex open fracture dislocations. In the context of high energy trauma, the patient should first be assessed for life-threatening injuries. A thorough history and clinical examination including neurovascular assessment should then be completed. Antero-posterior and lateral X-rays are sufficient to confirm the diagnosis. Initial management includes immobilisation in an above elbow backslab, a sling and analgesia.

Owing to the pull of the triceps muscle which attaches to the tip of the olecranon, fracture displacement is common and surgical intervention is often required, usually with good outcomes. Surgical techniques include tension band wiring, open reduction internal fixation with a pre-contoured locking plate and tension band suture fixation. Undisplaced fractures or displaced fractures in older patients can be managed conservatively with an above elbow cast for 4 weeks. This article covers applied anatomy, initial presentation, clinical assessment and evidence-based management.